Research ArticleVisual Acuity and Size of Choroidal Neovascularization in HighlyMyopic Eyes with a Dome-Shaped Macula

LuWang,1 Bin-wu Lin,1 Xiao-fang Yin,2Wei-lan Huang,3 Yi-zhiWang,4 and Long Pang 1

1Department of Ophthalmology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510000, China2Department of Ophthalmology, Foshan Hospital Affiliated to Southern Medical University,'e Second People’s Hospital of Foshan, Foshan 528000, China3Physical Examination Center, 'e 'ird Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510000, China4Guangzhou University of Chinese Medicine, Guangzhou 510405, China

Correspondence should be addressed to Long Pang; 1907757091@qq.com

Received 7 September 2020; Revised 26 October 2020; Accepted 29 October 2020; Published 23 November 2020

Academic Editor: Alessandro Meduri

Copyright © 2020 Lu Wang et al. +is is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. A dome-shapedmacula (DSM) is an inward convexity or anterior deviation of themacular area. DSM is believed as aprotective factor in maintaining visual acuity in highly myopic eyes. Objective. To investigate the correlation between best-corrected visual acuity (BCVA), choroidal neovascularization (CNV), and a dome-shaped macula (DSM) in highly myopic eyes.Methods. In this retrospective and observational case series study, BCVA tests and optical coherence tomography (OCT) wereperformed in a total of 472 highly myopic eyes (refractive error ≥6.5 diopters or axial length ≥26.5mm). CNV was detected byfundus fluorescein angiography (FFA), and the CNV area was measured by ImageJ software. BCVA, central retinal thickness(CRT), and the CNV area were compared between highly myopic eyes with and without DSM. Results. +e data revealed 13 eyeswith DSM complicated by CNV, for an estimated prevalence of 25%.+e eyes with CNV in the DSM group showed worse BCVAthan those in the non-DSM group (1.59± 0.69 and 0.63± 0.64, respectively, p< 0.05), and the CNV area in the DSM group waslarger than that in the non-DSM group (2793.91± 2181.24 and 1250.71± 1210.36 pixels, respectively, p< 0.05). After excluding theeyes with CNV, the DSM group had better BCVA than the non-DSM group (0.33± 0.17 and 0.44± 0.48, respectively, p< 0.05);however, no significant difference was observed in the CRTof eyes with CNV between the DSM group and the non-DSM group.Conclusion. +ese results show that DSMmight be a protective mechanism for visual acuity, but its protective capability is limited.DSM eyes have better visual acuity within the protective capability. If a more powerful pathogenic factor exceeding the protectivecapability is present, then the eye will have more severe CNV and worse visual acuity.

1. Introduction

A dome-shaped macula (DSM) is an inward convexity oranterior deviation of the macular area that was originallydefined by Gaucher et al. in 2008, who described DSM as anew type of myopic posterior staphyloma using opticalcoherence tomography (OCT) [1]. With the development of3D MRI, other researchers found that DSM develops earlierthan staphyloma formation in some patients. Recent studieshave indicated that DSM can be found in emmetropic eyesand might be an independent factor for lesions [2, 3].

+ere are still many uncertainties regarding the path-ophysiology of DSM configuration. Several theories have

been published, such as scleral infolding, choroidal thick-ening, and vitreomacular traction, but none has beenconfirmed. Choroidal neovascularization (CNV), reti-noschisis (RS), and serous retinal detachment (SRD) are themain complications that occur in DSM eyes [1, 4–9]. Amongthese complications, CNV was the most frequent, present inmore than one-third, and it is a vital factor that threatens thevisual acuity of highly myopic patients [8, 10]. +inning ofthe sclera owing to long-term changes and elongation of theaxis may develop CNV and other macular complicationswhich could cause visual impairment in highly myopic eyes[11]. Prior reports have found an increase in the macularsclera and macular choroidal thickness in pathologic myopic

HindawiJournal of OphthalmologyVolume 2020, Article ID 8852156, 7 pageshttps://doi.org/10.1155/2020/8852156

eyes with DSM, and macular CNV was detected significantlymore frequently in eyes without DSM than in eyes with DSM[12, 13]. It seems that greater bulge height and thickerchoroid in highly myopic eyes with DSM may protectagainst the development of myopic CNV [13], given thatDSM may serve as a compensatory mechanism. In addition,although myopic macular retinoschisis was detected morefrequently in highly myopic eyes with DSM, the fovealretinoschisis was less common in eyes with DSM [9, 13].+us, it is believed that DSM was a protective factor inmaintaining visual acuity in highly myopic eyes.

In this study, we evaluated the visual acuity of patientswith highly myopic eyes with or without DSM. +e featuresof CNV and the central retinal thickness (CRT) in patientswith highly myopic eyes with CNV were also investigatedand analyzed by fundus fluorescein angiography (FFA) andoptical coherence tomography (OCT), respectively, whichmay provide evidence to further understand thisphenomenon.

2. Materials and Methods

In this retrospective observational study, the medical recordsof patients with highly myopic eyes from the GuangdongProvince Traditional Chinese Medical Hospital and +eSecond People’s Hospital of Foshan were reviewed. +isstudy adhered to the principles of the Declaration of Hel-sinki. High myopia was defined as a refractive error ≥−6.5 Dor an axial length of >26.5mm. Eyes with an inferiorstaphyloma due to congenital tilted disc syndrome or withother vision-threatening pathologies such as corneal opacity,severe cataracts, age-related macular degeneration, and di-abetic retinopathy were excluded from the study. DSM wasdefined as an inward bulge of the macular RPE >50 µm in thehorizontal or vertical section of the OCT image [1].

All patients underwent a full ophthalmic examinationincluding a best-corrected visual acuity (BCVA) test, to-nometry, optometry, slip lamp examination, funduscopy,axial length (AL) measurements (IOL Master 500, version7.7, Carl Zeiss AG, Dublin, California, USA), and OCT (3DOCT-2000, Topcon, Tokyo, Japan; Spectralis HRA+OCT,Heidelberg Engineering Inc., Germany). Vertical and hor-izontal line scans 6mm in length and centered on the foveawere obtained from OCT. +e height of the macular bulgecompared with the bottom of the staphyloma was measuredby tracing a line tangent to the outer border of the RPE at thebottom of the staphyloma. +en, the distance between theRPE at the foveal center and the newly traced line wasmeasured, representing the height of the bulge.

Macular thickness was measured according to the EarlyTreatment of Diabetic Retinopathy Study (ETDRS) areas,which were defined by three concentric rings (central, inner,and outer circles) centered on the fovea, with diameters of 1,3, and 6mm. Other macular changes on OCT, such asintraretinal fluid (IRF), subretinal fluid (SRF), subretinalhyperreflective material (SHRM), myopic foveoschisis(MFS), the integrity of ellipsoid zone (EZ), and the type ofCNV, were also recorded. Subjects with suspected CNVunderwent FFA (TRC-50DX, Topcon, Tokyo, Japan;

Spectralis HRA+OCT, Heidelberg Engineering Inc., Ger-man). +e size of the CNV area was measured on FFA; areaswith early hyper fluorescence and leakage were consideredareas of CNV. All image processing and analyses werecarried out using public domain software (ImageJ, v1.41d,available at http://rsb.info.nih.gov/ij). A single experiencedexaminer blinded to the clinical diagnoses of the subjectsperformed the OCT and FFA examinations.

2.1. Statistical Analysis. All statistical analyses were per-formed with SPSS forWindows software (version 17.0, SPSS,Inc., Chicago, IL). All values are expressed as mean-± standard deviation. Pearson’s chi-square tests were used tocompare categorical variables. Student’s t-test was used toexplore differences in means among continuous variables,and the Mann–Whitney test was performed when thesample data were not normally distributed. +erefore, theage, BCVA, size of CNV, and CRT were compared betweenthe 2 groups using Student’s t-test. +e incidence of DSM inboth sexes was compared between groups using chi-squaretests. +e IRF, SRF, SHRM, FS, type of CNV, and integrity ofEZ were compared between groups using chi-square tests. Ap value < 0.05 was considered statistically significant.

3. Results

3.1. Characteristics of Highly Myopic Eyes with DSM. A totalof 472 highly myopic eyes of 366 patients from theGuangdong Province Traditional Chinese Medical Hospitaland+e Second People’s Hospital of Foshan were identified.+e database from October 2016 to April 2018 was included.Of the 472 eyes, 52 eyes (11.02%) of 42 patients had DSM(28/186 and 14/180, χ2 � 4.77, p< 0.05, Table 1). +e averageages of patients with and without DSMwere 64.7± 15.43 and59.62± 15.21, respectively (t� 2.28, p> 0.05, Figure 1(a)).+e other details are shown in Table 1.

Of the 472 myopic eyes, 40 eyes harbored CNV (8.5%):13 eyes with DSM and 27 eyes without DSM.

+e BCVA of myopic eyes with and without DSM was0.64± 0.66 and 0.44± 0.50, respectively, which indicates thatthe DSM group had overall worse visual acuity than the non-DSM group (t′� 2.2, p< 0.05, Table 1 and Figure 1(b)).Considering that CNV is a crucial complication that in-fluences visual acuity, we further divided these 472 eyes intofour subgroups: DSM eyes with CNV (13 eyes), non-DSMeyes with CNV (27 eyes), DSM eyes without CNV (39 eyes),and non-DSM eyes without CNV (393 eyes). +e averageBCVA in the four groups was 1.59± 0.69, 0.63± 0.64,0.33± 0.17, and 0.44± 0.48, respectively (Table 1).+e resultsshowed that DSM eyes with CNV had poorer visual acuitythan non-DSM eyes with CNV (t� 4.23, p< 0.05, Table 1and Figure 1(c)). Once the eyes with CNVwere excluded, theBCVA was better in eyes with DSM than in eyes withoutDSM (t′� −2.96, p< 0.05, Table 1 and Figure 1(d)).

3.2. Characteristics of Highly Myopic Eyes with CNV. Wefurther analyzed 40 highly myopic eyes that had been di-agnosed with CNV by OCT and FFA. Of all 40 eyes, 13

2 Journal of Ophthalmology

highly myopic eyes hadDSM, and 27 eyes did not have DSM.+e average age was not significantly different between thetwo groups (65.33± 17.53 and 64.28± 15.73, respectively,p> 0.05, Table 2). +e general characteristics of the highlymyopic eyes associated with CNV are presented in Table 2.Notably, BCVA was significantly worse in DSM eyes withCNV compared to non-DSM eyes with CNV (1.59± 0.69and 0.63± 0.64, respectively, t′� −2.96, p< 0.05, Table 1 andFigure 1(c)).

3.3. 'e Size of CNV and Central Retinal 'ickness (CRT) inHighly Myopic Eyes. +e size of the CNV lesion and mean

CRT were measured in 40 myopic eyes that had been di-agnosed by OCT and FFA. +e sizes of the selected CNVareas were 2793.91± 2181.24 pixels in the DSM group and1250.71± 1210.36 pixels in the non-DSM group (t′� 2.18,p< 0.05, Table 2 and Figure 2(g)). +e CRTs were284.25± 115.34 μm in the DSM group and 353.35± 184.7 μmin the non-DSM group (t� −1.197, p> 0.05, Table 2 andFigure 2(h)).+ese results indicated that the DSM group hadlarger CNV lesions than the non-DSM group; however,other potential factors affecting visual acuity, such as theaverage CRT, IRF, SRF, SHRM, FS, integrity of the EZ, andtype of CNV, were not significantly different between thetwo groups (Table 2).

Table 1: Characteristics of highly myopic eyes with and without DSM.

DSMp value

Present (n� 52) Absent (n� 420)No. of eyes (patients) 52 (45) 420 (321)Age (years) 64.7± 15.43 59.62± 15.21 >0.05Sex (male/female) 14/28 166/158 <0.05BVCA (logMAR)Total 0.64± 0.66 0.44± 0.50 <0.05HM without CNV 1.59± 0.69 0.63± 0.64 <0.05HM with CNV 0.33± 0.17 0.44± 0.48 <0.05BVCA, best-corrected visual acuity; HM, highly myopic eyes.

0

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Figure 1: Average age and logMAR BCVA in patients with or without DSM.+ere is no statistical difference in the average age in DSM andnon-DSM patients (a). +e logMAR BCVA is significantly higher in patients with DSM compared to the patients without DSM (b). Inpatients with CNV, the logMAR BCVA is much higher in patients with DSM than non-DSM patients (c). In patients with no CNV lesions,the logMAR BCVA is much lower in patients with DSM than in patients without DSM (d).

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Table 2: Characteristics of highly myopic eyes with CNV.

DSMp value

Present (n� 13) Absent (n� 27)No. of eyes (patients) 13(12) 27(25) —Age (years) 65.33± 17.53 64.28± 15.73 >0.05Sex (male/female) 4/8 6/19 >0.05+e area of CNV (pixels) 2793.91± 2181.24 1250.71± 1210.36 <0.05+e CRT (μm) 284.25± 115.34 353.35± 184.7 >0.05+e IRF (Y/N) 1/12 5/22 >0.05+e SRF (Y/N) 4/9 13/14 >0.05+e SHRM (Y/N) 3/10 8/19 >0.05+e type of CNV (1/2) 2/11 2/25 >0.05+e integrity of EZ (Y/N) 1/12 3/24 >0.05BVCA: best-corrected visual acuity; HM: highly myopic eyes; CRT: central retinal thickness; CNV: choroidal neovascularization; IRF: intraretinal fluid; SRF:subretinal fluid; SHRM: subretinal hyperreflective material; EZ: ellipsoid zone.

DSM Non-DSM

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Figure 2:+e area of CNV and the CRT in patients with CNV lesions.+e pictures show typical FFA (a, d) and OCT (b, c, e, f ) images in thepatients with or without DSM.+e area of CNVwas dramatically higher in DSM patients than in non-DSM patients. No statistical differencehas been found in central retinal thickness between the two groups.

4 Journal of Ophthalmology

4. Discussion

In our study, DSM was observed in 52 of the 472 highlymyopic eyes (11.02%), which is a similar rate to those re-ported by Ohsugi et al. (9.3%), Gaucher et al. (10.7%), Chebilet al. (12.0%), and I-Chia et al. (20.1%) [1, 8, 11, 14–16]. +epresent research showed that the DSM rate varies from 9.3%to 20.1%. +e differences may be due to variations in thenumber of samples, differences in the inclusion criteria, anddifferences in the race of patients included in these studies.

+e association between DSM and visual acuity remainscontroversial [9, 14, 17, 18]. DSM was initially believed to bea threat to visual acuity when first described by Gaucher et al.because of the association between DSM and several mac-ulopathies, such as CNV, RS, SRD, foveal detachment, andRPE atrophy [1].+e incidence of maculopathy in DSM eyesis much higher than that in eyes without DSM [9, 19, 20].

+is view was further confirmed by subsequent studiesthat focused on the morphological features of DSM, whichfound that DSM results from the relative thickening of themacular sclera and may lead to pigment epithelial detach-ment (PED). Long-term changes and elongation of the axismay thin the sclera, which leads to the development of CNVand causes visual impairment [11]; however, a larger-scalestudy suggested a different point. In a study involving 1118highly myopic eyes, macular complications were morecommon in DSM eyes than in non-DSM eyes, and the mostcommon complication was extrafoveal RS [9]. Foveal RS andCNV, two of the main threats to visual acuity, are much lesscommon in DSM eyes than in non-DSM eyes [9, 10, 21].Another study involving 1384 highly myopic eyes revealedthat the incidence of foveal RS was also much lower in eyeswith DSM than in those without DSM [16]. +ese resultsindicate that DSM might be a protective mechanism forvisual acuity.

In this study, we found that the BCVA of patients in thenon-DSM group was better compared to the DSM group.+is result was confusing in view of the protective nature ofDSM for visual function in highly myopic eyes. Given thissituation, we compared the factors that may impair visualacuity including CRT, IRF, SRF, SHRM, FS, integrity of theEZ, type of CNV, and size of the CNV area between the twogroups. +e results showed that the CRT, IRF, SRF, SHRM,integrity of the EZ, and type of CNV were not significantlydifferent between the two groups. +e highly myopic eyeswith DSM showed a larger CNV size than highly myopiceyes without DSM. Further analysis confirmed that the eyeswith CNV in the DSM group showed worse BCVA thanthose in the non-DSM group. We hypothesize that patientsin the DSM group had worse BCVA than patients in thenon-DSM group due to the lower BCVA of eyes with CNVin the DSM than of eyes with CNV in the non-DSM group.After excluding eyes with CNV, the BCVA was better in theDSM group than in the non-DSM group. Additionally, asshown in the FFA results presented in Figure 2, the CNVarea was larger in patients with CNV and DSM, but leakageand staining were also apparent. In patients with CNVwithout DSM, only leakage was observed. +is result indi-cated the DSM patients have a longer duration of illness

before asking a doctor for relief. In this case, we consider thatDSM might be a protective mechanism for visual acuity, butits protective capability is limited. Less CNV and bettervisual acuity were found in DSM eyes within the protectivecapability. If a more powerful pathogenic factor exceedingthe protective capability is present, then more severe CNVand worse visual acuity will occur. +e development of CNVin DSM eyes indicates a powerful pathogenic factor, such asan elevated level of vascular endothelial growth factor(VEGF) and refractory macular diseases.

+e precise cause of DSM remains unknown; however,several theories ranging from localized choroidal thickeningto scleral infolding to vitreomacular traction have beenpostulated to underlie the mechanism and pathophysio-logical processes that lead to the formation of DSM in highlymyopic eyes [22]. Imamura et al. showed that DSM resultedfrom the relatively localized thickening of the sclera underthe macula in highly myopic eyes with enhanced depthimaging OCT [5]. +e thick sclera in DSM eyes may act as amacular buckle-like mechanism, thereby alleviating trac-tional forces over the fovea, preventing foveal RS or RD(retinal detachment), and protecting visual function [9].Such anatomical features may minimize refractive errorsand maintain emmetropization in highly myopic eyes.Among the vision-threatening complications that can occurin highly myopic eyes, CNV is a key factor that can lead tosevere visual impairment [23]. Different views exist aboutthe relationship between the incidence of macular CNV andthe presence of DSM. CNV has been reported to be a fre-quent complication of DSM (12.2%, 20.8%, 25.0%, 41.2%,and 47.8%) in previous studies [10, 24, 25]; however, Lianget al. reported that the incidence of macular CNV was as-sociated with age but not the presence of DSM. +emechanism of CNV formation is unclear [8]. Akyol et al.considered that CNV development may be related to cho-roidal and retinal blood flow changes [26]. Ohsugi et al.reported that CNV formation is caused by thinning of thecentral sclera owing to elongation of the AL [11]. Other riskfactors for the formation of CNV have been reported, such aslacquer cracks, choroidal thinning, patchy atrophy, and thepresence of a choroidal filling delay [27, 28]. +inning of thesclera owing to long-term changes and elongation of the axismay promote CNV development and cause visual impair-ment. +us, in DSM eyes, a thick sclera may be a potentialprotective factor against CNV formation.+e bulge height ofDSM without the complication of CNV is significantlyhigher than that of DSM with the complication of CNV[11, 29].

In the current study, CRT, IRF, SRF, SHRM, FS, integrityof the EZ, and the type of CNV did not significantly differbetween myopic eyes with and without DSM. In view of thisobservation, these factors are not themain cause of the visualacuity differences between eyes with CNV in the DSM groupand those in the non-DSM group. +e eyes with CNV in theDSM group had a larger CNV area than those in the non-DSM group. In a previous study, those with a larger CNVarea developed more chorioretinal atrophy (CRA) thanthose with a smaller CNV area, which may explain why lowBCVA was observed in myopic eyes with CNV and DSM

Journal of Ophthalmology 5

[30]. As previously mentioned, the development of CNV inDSM eyes indicates the presence of a powerful pathogenicfactor.+e level of VEGF is the key factor in the formation ofCNV.+erefore, the VEGF level may be higher in DSM eyeswith CNV than in those without. +is point of view wasconfirmed in a previous study that found that patientswithout DSM might be more sensitive to intravitreal rani-bizumab therapy in early stages compared to patients withDSM [31].

Our study has several limitations. First, this retrospectivestudy was subject to the potential inherent limitations as-sociated with this study design. Second, we included patientswho visited the Guangdong Province Traditional ChineseMedical Hospital and +e Second People’s Hospital ofFoshan.+us, the results obtainedmay not exactly reflect thegeneral myopic population. +ird, all patients were Chinese,and we did not include patients of other ethnicities. Fourth,patients with visual symptoms were more likely to be en-rolled in the study, which might have resulted in a highincidence of CNV. Finally, no precise method to calculatethe CNV size has been established. FFA and OCT arecommon methods and showed high consistency with pre-vious research [32].

In summary, DSM is a progressive anomaly of theposterior pole of myopic eyes. Our study shows that DSMmay play an important role in protecting highly myopic eyescomplicated by severe maculopathy and maintaining goodvisual acuity initially; however, this protection is limited.When neovessels appeared, the size of the CNV area in-creased, and visual acuity worsened. +is work may providemore evidence in predicting the visual prognosis of patientswith highly myopic eyes and may provide additional insightinto the mechanism of pathologic myopia. +ese conclu-sions indicated that the highly myopic patients with DSMneed a more frequent follow-up to detect CNV in time. +eDSM eyes with CNV might need a higher dose or morefrequent intravitreal ranibizumab therapy in early stagesthan patients without DSM.

Data Availability

+e data used to support the findings of this study are in-cluded within the article.

Ethical Approval

+is retrospective observational study adhered to theprinciples of the Declaration of Helsinki.

Conflicts of Interest

+e authors declare that they have no conflicts of interest.

Authors’ Contributions

Lu Wang and Bin-wu Lin contributed equally to this work;Long Pang designed the study; Lu Wang, Bin-wu Lin, Xiao-fang Yin, Wei-lan Huang, and Yi-zhi Wang performed datacollection and management; Bin-wu Lin performed data

analysis and interpretation; and Lu Wang and Bin-wu Linwrote and reviewed the manuscript.

Acknowledgments

+e authors gratefully acknowledge the valuable cooperationof the medical staff in Guangdong Provincial Hospital ofChinese Medicine and +e Second People’s Hospital ofFoshan, for collecting the data.

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